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P - 76681IJinnesota Dep enf of Labor and Industry 443 Lafayette. oad North Si Pauf, M 5155-4342 Phone: (6 2845064 T1Y/MR (651) 297-4198 wvrw.ele 'citv.state.mn.us � Homeowner R Date Rough-fn tnspecii�n Required? �' i� �� Homeowner Must Schedule All Rou h-In Address of Inspection - Street ni�S'v,�v Qw � Owner Name �o �, QA � �-N Owner Telephone Number(s) - Include Area Code(s) ?c� 3- s � � - 3 �� � Owner Maiting Address — Street '�..,_ z RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER PERMIT # ��� �� - � I �Y� RECEIVED: �SEP 7' %nn% :$� for Electricaf Ins ection Yes Inspecfion Oiher Than Rough-ln: ❑ Ready Now. �ections Homeowner Must S�hedufe Ail Final !ns ections ❑ WII Schedule City/Township County ��' � �L�� ,�rvoill� Project Descripii Movc" ��xe�Tl••.� f2,�c�;p?�c9� t �AOp�ns �NC? i�Ot��?/UNf►� 2C:�' s r t w��k��J City State Zip Code Owner E-mail Address t�ectncai umrcy ��1L�C N� I�SG O, t�1 L�� By signing this do , certify fhat 1 am the owner as defined by Minn. Stat § 326.01 and �nrill legally perform the electrical work Owner Signatur Fee Calculation New Home or Associated Structure Ezisting HomelStructure Remodel or Addiiion New Home Service/Power Supply 0- 400 ampere @$35 New Home Senricelf'ower Supply 401 - 800 ampere @$60 New Home Feeders/Circuits Up to 30 Feeders/Circuits - $100 New Home - More than 30 Feeders/Circuits (in add'Rion to above) ( ) Feeders/Circuits Up To 200 A@$6 Each Other (Specify) Detached Garage or Other Associated Structure New Service/Power Supply New Feeders/Circuits 0 - 400 ampere @ $35 ( ) @ $6 Each New Service/Power Supply �1Power Su�spiy .rs/Circuits - Up to 15 FeedersJCircuits @ $I .��r��„��r� _ nn„ro n, � - 400 ampere � $35 401 - 8W ampere @ $60 16to30(c�$100 3D Feeders/Circuits to 200 A (D_ $6 Each ( ) Feeders/Circuits $2 Each � Detached Garage or Other Associated Structure New 5ervice/Power Suppty New Feeders/Circuits Reconneded Feeders/Circuits 0 - 400 ampere @ $35 ( ) @ $6 Each ( ) @ $2 Each Tot31 (the fee calculated above or $35 multiplied Tot81 (the fee calculated above or $35 multiplied by the number of required inspection trips, , by the number of required inspection trips, —7� whichever is greater) whicheVer is greater) �, `(/ Requests for Elecirical Inspection (REI) with a fee of $250 or less exp[re 12 months from the filing date. The owner must have the work completed within the 12 month period or submit another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REI to another. A service char e of S30 will be added for all dishonored cn�cks. I hereby certify that I inspeGed the electrical instatlation herein on the dates stated: For Department Use Onfy Rough - In Inspection(s) � Date � L ��°� � � Final lnspect Date Z-?7-c This material can be made available in different forms, such as large print, Braille or on a tape. To request, TDD (651) 297-4198. REI 01 (6/07) 1-B00-342-5354 (DIAL-DLI) Voice or